Community nurse Ruth Chorley helps deliver health and social care in Oldham, the most deprived town in England.
Photograph: Jason Lock

Lisa Baxter*, a mother of three from Oldham, was trapped with a violent partner, difficulties controlling her children, threats of homelessness and frightening debt. Her only ways of coping with her desperation were by abusing drugs and alcohol, and frequent appointments with her GP for antidepressants – until she was referred to community nurse, Ruth Chorley.

I don’t know what I would have done without Ruth. Without her, I think I would have had my children taken off me

Since the 28-year-old started seeing Chorley five years ago at Hill Top surgery, in Fitton Hill, Oldham – as part of a groundbreaking scheme aimed at helping the most deprived families – she has stopped abusing drugs and alcohol, is securely rehoused, her ex-partner is in prison, her children attend school and she manages her finances with only occasional support. Her mental and physical health are transformed and her GP attendances are a fraction of what they once were.

Baxter says: “I don’t know what I would have done without Ruth. Without her, I think I would have had my children taken off me. I would not have been able to cope with social services. Before I started seeing her, I was just being seen by the doctor, given tablets and sent away, but it wasn’t any help, so I would be back again.”

Chorley is a focused care practitioner – one of four employed by Hope Citadel Healthcare, a not-for-profit community interest company, to lead a pioneering approach to delivering healthcare to the most needy families in its four Greater Manchester NHS GP practices, by filling in the gaps between health and social care.

A visit to Hill Top surgery overlooking the former mill town of Oldham, perfectly illustrates how this transformation in Baxter’s life has come about. Chorley emerges with Baxter, having been on the phone for more than an hour on her behalf. She has arranged food vouchers and funds to pay for three school uniforms, and has prevented the cancellation of Baxter’s child tax credit. She has also helped Baxter write a letter of appeal against the cancellation of her housing benefit.

Chorley: ‘How can you expect patients to look after their health, when they don’t know where they will be living next week?’ Photograph: Jason Lock

Passionate about her work, Chorley says: “How can you expect patients to look after their health, when they don’t know where they will be living next week? You can not separate people’s physical health from their psychological, social and spiritual health.”

The reality of doctoring in Oldham is stark. Oldham is the most deprived town in England, according the Office for National Statistics, with 65.2% of its local areas in the most deprived 20%. Men and women in these areas can expect to die more than 10 years sooner than inhabitants of Trafford – Greater Manchester’s most affluent suburb.

Clinical director of Hope Citadel Healthcare and GP at Hill Top surgery, Dr John Patterson kick-started the Focused Care scheme from a belief that social conditions determine heath and that those in greatest need are the least likely to receive it. Patterson says: “In areas of deprivation you need more multifactorial medicine and psychosocial support.”

He asked Chorley – because of her reputation as an energetic champion of families in poverty – to design a scheme in 2010 operating from the Fitton Hill practice, to support frequent attendees at the surgery with complex problems.

Recent figures show something of the scale of human need she and her colleagues face. Of the 120 families on Focused Care in 2014-15, 92% presented with mental health issues, 58% of households had housing problems and 17 women disclosed domestic violence.

The scheme took off and Patterson was astonished by the two-year figures. Of the initial 50 to 60 households dealt with by Chorley, 24 had stopped using A&E inappropriately, 25 no longer had parenting problems, 10 had stopped abusing alcohol and 12 homes no longer had a domestic violence problem.

Chorley has supported a man through insolvency and encouraged him to stop smoking and drinking. Photograph: Jason Lock

Audits of the 160 families receiving Focused Care over the four Hope Citadel surgeries show that they visit A&E 57% less in the year following intervention. Smear rates over the four practices have rocketed from around 40% to 94%, while at Hill Top surgery alone, 91% of over 65s have had their flu vaccine, outstripping the target of 80%.

A patient can be referred to Focused Care by health staff, social care workers or even police. In each case a patient is seen, problems identified and a care plan drawn up, tackling anything from immigration to parenting and benefit problems. The practitioner then contacts or visits the family on a regular basis and supports them in whatever way is most appropriate for their wellbeing.

It’s usually a painstaking task unpicking the problems. Chorley has supported Baxter through the trial and jailing of a former abusive partner. In another case, she helped a man through insolvency and encouraged him to stop smoking and drinking, enabling him to become a mover and shaker in his local housing association.

Just occasionally Chorley’s job can be short and simple – accessing £20 from a Hill Top practice fund to pay the taxi fare to enable a woman refugee to leave her violent husband with her children.

Hope Citadel is now working with Shared Health Foundation – a charity centred on identifying good practice and using the Greater Manchester health devolution agenda to roll it out into the most deprived parts of the conurbation.

Patterson says: “We call Focused Care the ‘Macmillan Service for deprivation’. We want to have an impact on the whole community – not just our patients.”

*Name has been changed

Doctors Working in Deprivation will be held on Wednesday 28 September at Gorton Monastery in Manchester from 8.30am to 4.30pm. To book a free place please register.